Established in 1844, our Journal is one of the oldest in the country. To learn more about the Journal and how to submit articles, please visit https://lsms.org/page/JLSMS.
JOURNAL OF THE LOUISIANA STATE MEDICAL SOCIETY VOL 174 | ISSUE 1 | SUMMER 2022
SINE DIE: 2022 LEGISLATIVE SESSION IS A WRAP
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VOL 174 | ISSUE 1 | SUMER 2022 CONTENTS
CHIEF EXECUTIVE OFFICER Jeff Williams
JOURNAL BOARD K. Barton Farris, MD Secretary/Treasurer, Richard Paddock, MD Anthony Blalock, MD
4 “ASK WHAT YOU CAN DO FOR YOUR PROFESSION!” 5 FROM AROUND THE STATE 6 MEWA ANNOUCEMENT: SAVE 10-15% 8 GROWING SOFT TISSUE MASS WITHIN THE RIGHT GROIN OF A YOUNG MALE PATIENT 10 STUDENT ABSTRACTS
L.W. Johnson, MD Fred A. Lopez, MD
LSMS 2021 BOARD OF GOVERNORS OFFICERS President, William Freeman, MD Past President, Katherine Williams, MD President-Elect, John Noble, Jr., MD Vice President, George Ellis, Jr., MD Speaker of the House, T. Steen Trawick, MD Vice Speaker, R. Reece Newsome, MD Secretary/Treasurer, Richard Paddock, MD Chair, COL, David Broussard, MD COUNCILORS District 1 Member, Myra Kleinpeter, MD District 2 Member, Vacant District 3 Member, Allen Vander, MD District 4 Member, Richard “Rick” Michael, MD District 5 Member, Gwenn Jackson, MD District 6 Member, Michael Roppolo, MD District 7 Member, Brian Gamborg, MD District 8 Member, Lance Templeton, MD District 9 Member, Andy Blalock, MD District 10 Member, Nicholas Viviano, MD SECTION REPRESENTATIVES Senior Physician Member, Marcus Pittman, III, MD Young Physician Member, Amberly Nunez, MD Resident/Fellow Member, Blake Denley, MD Medical Student Member, Brittany Wagner Employed Physician Member, Matthew Giglia, MD Private Practice Physician Member, Vicki Steen, MD
10 RESIDENT ABSTRACT WINNERS 11 STUDENT ABSTRACT WINNER
12 LAMPAC MEMORANDUM 14 LEGISLATIVE RECEPTION 15 WHITE COAT WEDNESDAY
16 2022 REGULAR LEGISLATIVE SESSION IS A WRAP 19 2022 LEGISLATIVE SESSION: BY THE NUMBERS 20 ADMINISTRATIVE SIMPLIFICATION BILLS 22 VACCINATIONS IN 2022 23 2022 VACCINATION RELATED LEGISLATION
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With the 2022 Louisiana Regular Legislative Session coming to a close, we have much to be grateful for as a profession and many to thank. As the Chair of the Council on Legislation for the Louisiana State Medical Society, I want to start by thanking you, the members, for responding to our ask for your participation and for making your voice heard in Baton Rouge this past year. Early in the session, we hosted the 2022 Legislative Reception and White Coat Wednesday events. While the details of these events will be chronicled elsewhere, suffice it to say that for two years in a row, we have “outgrown the facility” based upon your turnout and willingness to engage. With well over 120 members in attendance this year, there can be no doubt that our society is experiencing a new “finest hour” of professional advocacy. Next to thank is your Council on Legislation. This is the committee or “council” of the society, made up of individual members (one from each District), who work year-round to ensure success when the legislative session arrives. In addition to attending the fifteen plus meetings we hold every year, they offer strategy and insights into key issues and relationships at the Capitol based, in many cases, on decades of experience in the Legislative process. We do Sunday evening conference calls throughout session in addition to the three or so other meetings we hold on your behalf each year. You would be incredibly proud of your fellow members if you witnessed the commitment they bring to the table in this effort. They are truly advocacy warriors for the profession! I would also be remiss if I didn’t highlight the incredible work of our LSMS Governmental Affairs team, especially Maria Bowen, our Vice President of Governmental Affairs and Lauren Bailey, our Vice President of Legal Affairs. They work tirelessly, year- round, but especially during session, to ensure your objectives, as described in LSMS policy, are achieved. Maria has completed her fourth session now with the LSMS, but it is hard to imagine where we would be without her. When she joined, we discussed how priority number one would be to re-engage the grassroots membership of the LSMS. I am comfortable, based upon the success of White Coat Wednesday, in saying that this crucial first step is achieved. “ASK WHAT YOU CAN DO FOR YOUR PROFESSION!” DAVID BROUSSARD, MD - Council on Legislation for the Louisiana State Medical Society, Chair
I do get asked by members throughout the year what they can do to help become better advocates for the profession. There is no question that the answer is to form a relationship with your individual state Senator and Representative and support them politically. Starting such a relationship is easiest to accomplish with a first-time candidate, but in my experience, even established elected officials are surprisingly receptive if you reach out to them outside of the time-crunch of the legislative session. Many of you are already aware of the members from growing up together or interacting casually in your personal lives, so that makes the introductions easier. It also helps if the first time you are reaching out to them, you simply introduce your profession along with some of your “feel good” priorities (making telemedicine better or helping with the opioid epidemic, as examples) and don’t have a specific “ask.” This budding relationship will be developed even further when you have the opportunity to work on or contribute to their next campaign. These efforts don’t bring a direct return, but will help you in getting their attention during the busy season of session and at least allow you the opportunity to articulate your position on ways to help improve legislation they are considering.
Don’t hesitate to approach me at the upcoming LSMS House of Delegates in August if you have questions and want to get more involved in professional advocacy. We will no doubt face big challenges in the coming years and we will need you at the table with us!
THERE IS NO QUESTION THAT THE ANSWER IS TO FORM A RELATIONSHIP WITH YOUR INDIVIDUAL STATE SENATOR AND REPRESENTATIVE AND SUPPORT THEM POLITICALLY.
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Creating & Retaining a High-Functioning Team Tuesday, May 3, 2022
Drs. Steen Trawick & Christina Notarianni
Drs. Joseph Bochinni & John Vanchiere
Thank you Willis-Knighton Health System for hosting the NLMS Quarterly Meeting and 1-hour CME at the WK Eye Institute on Greenwood Road. The physicians in attendance earned 1 hour of FREE CME and enjoyed an open bar and their choice of either filet or snapper for dinner. The guest speaker was Teri Deabler, CMPE, COE practice management consultant at the Texas Medical Association. With her 25+ years experience in healthcare management, Teri kept everyone engaged with motivating tips on how to create a high-functioning healthcare team. The guest speaker was Teri Deabler, CMPE, COE practice management consultant at the Texas Medical Association. With her 25+ years experience in healthcare management, Teri kept everyone engaged with motivating tips on how to create a high- functioning healthcare team. Drs. Steen Trawick & Christina Notarianni Drs. Steen Trawick & Christina Notarianni Drs. Joseph Bochinni & John Vanchiere Thank you Willis-Knighton Health System for hosting the NLMS Quarterly Meeting and 1-hour CME at the WK Eye Institute on Greenwood Road. The physicians in attendance earned 1 hour of FREE CME and enjoyed an open bar and their choice of either filet or snapper for dinner. FROM AROUND THE STATE QUARTERLY MEETING & 1-HOUR CME CREATING & RETAINING A HIGH-FUNCTIONING TEAM TUESDAY, MAY 3, 2022 Quarterly Meeting Creating & Retaining a Hig Tuesday, May 3
Drs. Joseph Bochinni & John Vanchiere Thank you Willis-Knighton Health System Meeting and 1-hour CME at the WK Eye I physicians in attendance earned 1 hour of bar and their choice of either filet or snapp Drs. John Bienvenue & Stephen White The guest speaker was Teri Deabler, CM consultant at the Texas Medical Associatio in healthcare management, Teri kept every on how to create a high-functioning health
Quarterly Meeting & 1-Hour CME Creating & Retaining a High-Functioning Team Tuesday, May 3, 2022
Dr. Ellie Hudnall & Casey Richer
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Drs. Joseph Bochinni & John Vanchiere Drs. Joseph Bochinni & John Vanchiere Thank you Willis-Knighton Health System for hosting the NLMS Quarterly Meeting and 1-hour CME at the WK Eye Institute on Greenwood Road. The physicians in attendance earned 1 hour of FREE CME and enjoyed an open bar and their choice of either filet or snapper for dinner. Drs. John Bienvenue & Stephen White Drs. John Bienvenue & Stephen White The guest speaker was Teri Deabler, CMPE, COE practice management consultant at the Texas Medical Association. With her 25+ years experience in healthcare management, Teri kept everyone engaged with motivating tips on how to create a high-functioning healthcare team. Dr. Ellie Hudnall & Casey Richer Dr. Ellie Hudnall & Casey Richer Drs. John Bienvenue & Stephen White
Drs. Steen Trawick & Christina Notarianni Drs. Steen Trawick & Christina Notarianni
Drs. John Bienvenue & Stephen W
Dr. Ellie Hudnall & Casey Richer Dr. Ellie Hudnall & Casey Richer Teri Deabler, TMA & Mrs. Mary Pat & Dr. Ed Morgan Dr. Eric Bicknel, Mr. Jaf Fielder, WK President & CEO, & Dr. Stephen White
Thanks for supporting th Thanks for supporting the NLM Thanks for supporting the NLMS!
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Teri Deabler, TMA & Mrs. Mary Pat & Dr. Ed Morgan Dr. Eric Bickn Dr. Stephen
Nearly 50 in attendance for the 1-hour CME
Nearly 50 in attendance for the 1-hour CME
Nearly 50 in attendance for the 1-hour CME
Thanks for supporting the NLMS! Thanks for supporting the NLMS!
Nearly 50 in attendance for the 1-hour CME Nearly 50 in attendance for the 1-hour CME
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4 Drs. John Bienvenue & Stephen White 5 Nearly 50 in attendance for the 1-hour CME 6 Teri Deabler, TMA & Mrs. Mary Pat & Dr. Ed Morgan
Drs. Randy Kirchner, Thomas Reilly, Jeff Faludi, & Dayne Hassell 7 Dr. Eric Bicknel, Mr. Jaf Fielder, WK President & CEO, & Dr. Stephen White 8 Drs. Randy Kirchner, Thomas Reilly, Jeff Faludi, & Dayne Hassell
Drs. Randy Kirchner, Thomas Reilly, Jeff Faludi, & Dayne Hassell 1 Drs. Steen Trawick & Christina Notarianni 2 Drs. Joseph Bochinni & John Vanchiere 3 Dr. Ellie Hudnall & Casey Richer
Teri Deabler, TMA & Mrs. Mary Pat & Dr. Ed Morgan Dr. Eric Bicknel, Mr. Jaf Fielder, WK President & CEO, & Dr. Stephen White
J LA MED SOC | VOL 174 | SUMMER 2022 5
MEWA ANNOUCEMENT: SAVE 10-15%
The Louisiana State Medical Society is pleased to announce our vision to deliver a LSMS- sponsored health plan to our members is becoming a reality. The Louisiana Department of Insurance is currently reviewing our application to provide health insurance to our members through a Multiple Employer Welfare Arrangement (MEWA.) Known as Advantage Physicians Healthcare Trust (APHT), we anticipate our plans will be approved this summer.
APHT will offer three health insurance plans to LSMS members that are closely modeled after existing Blue Cross Blue Shield of Louisiana (BCBS of LA) plans. BCBS of LA will serve as our claims administrator. Eligibility for the APHT health insurance plans includes:
1 APHT health insurance coverage is only open to active members of the LSMS, their families and full-time employees of their practices and their families. 2 APHT health insurance coverage is only open to residents of Louisiana. 3 At minimum of two subscribers in the practice must participate. As an example, a sole practitioner with a single full- time staff member participating is the smallest subgroup that we can accept. 4 To broaden the reach of the APHT health plans (and achieve lower costs), we have created a new category of membership in the LSMS – Affiliate Member. Any dentist licensed by the Louisiana State Board of Dentistry, or any medical professional licensed by the Louisiana Board of Medical Examiners, will be eligible for an Affiliate Membership in the LSMS, and may participate in APHT health plans and use our purchasing site. 5 Although the APHT health plans are modeled after three existing BCBS of LA plans, our goals is to reduce costs for a large majority of our members than the traditional BCBS of LA plans as applicants will be fully underwritten before coverage is initiated. Underwriting was common before the Affordable Care Act, but it will allow us to more accurately assess the risks associated with covering subscribers to our plans. 6 APHT health plan members will have complete access to the existing BCBS of LA network of providers and will carry a health insurance card co-branded with BCBS of LA and APHT logos. If you are currently a BCBS of LA member, your coverage will remain unchanged.
7 Unlike traditional health insurance plans, APHT plans can be purchased by LSMS members on an annual basis throughout the year – no more waiting for open enrollment. All plans started during the year will have a renewal date of January 1 the following year. 8 APHT is overseen by a group of five trustees drawn from the executive leadership of the LSMS its general membership. The primary objective of APHT and our board of trustees is to secure the lowest possible health care premiums with the broadest possible coverage for LSMS members. 9 You can obtain quotes and purchase APHT plans three ways. 1 Through your existing insurance broker relationships. 2 Contact the LSMS directly for an introduction to a DOI- licensed broker. 3 Visit the APHT website at www.aphtrust.com to complete you application electronically. The website will go live shortly after our application is approved by the DOI. 10 Finally, we have licensed and customized state-of-the-art health insurance back-end software to allow us to seamlessly automate the entire health insurance application, quoting, invoicing and payment processes. Through many months working diligently with insurance advisors, lawyers, actuaries, underwriters, Blue Cross Blue Shield of Louisiana, and our financial partners we are able to bring this dream to life. We encourage all of our members to apply for health insurance coverage through APHT so that we can grow and maintain this benefit for our membership for many years into the future.
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J LA MED SOC | VOL 173 | WINTER 2021
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GROWING SOFT TISSUE MASS WITHIN THE RIGHT GROIN OF A YOUNG MALE PATIENT Mitchell Ta, BS, Ahmed T. Rashad, MD, Neel D. Gupta, MD, Jeremy B. Nguyen, MD HISTORY 29 year- old male presents with 2 months of groin pain. Physical exam demonstrates a soft tissue mass within the right groin, which has increased in size.
Figure 1: Axial T1 MRI
Figure 2: Axial T2 MRI
Figure 3: Axial STIR MRI
F igure 4: Axial contrast-enhanced T1
Figure 5: Coronal contrast-enhanced T1
Figure 6: Axial CT
Figure 7: Axial FDG-PET fusion
Figure 7: FDG-PET with 3D ROI (MIP)
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IMAGING FINDINGS Figure 1
4 varieties – typical, myxoid (high water content), lipoma-like (containing adult fat, common in the thigh), and spindle cell 1,2 .
Well-circumscribed heterogenous T1 hyperintense right adductor intra/extramuscular mass with fat signal characteristics. Figure 2 Well-circumscribed heterogenous T2 hyperintense right adductor intra/extramuscular mass with fat signal characteristics. Figure 3 Well-circumscribed heterogenous STIR hyperintense right adductor intra/extramuscular mass. Figure 4 Well-circumscribed heterogeneously enhancing right adductor intra/extramuscular mass. Figure 5 Well-circumscribed heterogeneously enhancing right adductor intra/extramuscular mass.
Radiographs, Ultrasound with doppler interrogation, CT, and MRI are viable modalities to help differentiate hibernomas. On radiographs, hibernomas often appear as radiolucent masses without mineralization or osseous abnormalities. On ultrasound, hibernomas present as well-circumscribed, hyperechoic masses, with Doppler demonstrating hypervascularity. Arteriovenous (AV) shunting within hibernomas has been reported. AV shunting as well intrinsic hypervascularity, contraindicates core needle biopsy, especially involving deep lesions. The characteristics of hibernomas on imaging likely parallel the histological variants described earlier. Typical hibernomas demonstrate multiple prominent branching serpentine vascular structures on CT and MRI with low signal intensity on all MR pulse sequences. Lipoma- like (or spindle cell if located within the neck) hibernomas appear identical to fat on CT and MRI but with branching vascular structures. Myxoid type hibernomas, meanwhile, present with high water content 1,2 . Definitive treatment is resection. However, in terms of surgical resection in our case, the mass was also displacing muscle. Along the proximal deep lateral margin of the mass, one of the branches of the obturator nerve appeared to course directly into the tumor and was not salvageable. Additionally, there was an unusual area of fat collection at this same site. This collection was sent as a separate specimen to ensure that all of the tumor was resected and that no residual tumor tracked proximal along the obturator nerve. Pathology confirmed that there were fragments of hibernoma within the separate specimen. These lesions, however, have not been shown to recur, metastasize or develop into malignancies in the literature 1-3 . REFERENCES 1. Murphey MD, Carroll JF, Flemming DJ, Pope TL, Gannon FH, Kransdorf MJ. From the archives of the AFIP: benign
Figure 6 Well-circumscribed hypodense right adductor intra/ extramuscular mass.
Figure 7 Axial FDG-PET/CT fused images demonstrating significant FDG uptake within the right adductor musculature. Figure 8 3D Coronal PETCT MIP with significant abnormal uptake within the region of interest (Right Adductor Musculature) with SUV 18.7. Physiologic radiotracer uptake within the left ventricle myocardium, renal collecting system and the urinary bladder. DIFFERENTIAL DIAGNOSIS
musculoskeletal lipomatous lesions. Radiographics. 2004;24(5):1433-1466. doi:10.1148/rg.245045120
1. Hibernoma 2. Liposarcoma 3. Nonspecific Lipomatous Mass 4. Rhabdomyoma 5. Resolving hematoma FINAL DIAGNOSIS: HIBERNOMA DISCUSSION
2. Furlong MA, Fanburg-Smith JC, Miettinen M. The morphologic spectrum of hibernoma: a clinicopathologic study of 170 cases. Am J Surg Pathol. 2001;25(6):809-814. doi:10.1097/00000478-200106000-00014 3. Fnini S, et al. Hibernoma of the thigh. Ann Chir Plast Esthet 2011 Apr; 56(2):160-2. ACKNOWLEDGMENTS Mitchell Ta is a 4th year Medical Student at Tulane University School of Medicine in New Orleans, La. Ahmed T. Rashad MD is a PGYIII Resident in the Department of Radiology at Tulane University School of Medicine in New Orleans, La. Neel Dewan Gupta MD is a clinical and academic musculoskeletal radiologist in New Orleans and serves as a clinical assistant professor within the Department of Radiology at the Tulane University Medical Center. Jeremy Nguyen MD, FACR is clinical radiology professor within the Department of Radiology at the Tulane University Medical Center. Donald Olivares, Digital Imaging Specialist and Graphic Designer. ■
Hibernomas, named for resembling the brown fat of hibernating animals in 1914, are rare, benign fatty lesions that arise from vestigial fetal brown fat 1 . They are often painless and slow- growing. On physical exam, hibernomas are typically mobile, pliable masses that are warm to the touch, secondary to their hypervascularity. Macroscopically, they resemble lipomas in that they are largely well-circumscribed, encapsulated fatty lobulated masses that typically measure 5 to 10 cm in diameter. In terms of their incidence, hibernomas are most often seen in the 3rd or 4th decades of life with a slight female predominance. Hibernomas appear where normal brown fat occur, most commonly in the thigh 3 , occasionally in the shoulder, back, neck, chest, arm, and rarely within the retroperitoneum. Histopathologically, hibernomas have been categorized into
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STUDENT ABSTRACTS
Each year medical students from the five medical schools and residents from the eight Internal Medicine training programs in Louisiana are invited to submit abstracts for the Annual American College of Physicians (ACP) Resident and Student Meeting of the Louisiana Chapter. The content of these abstracts includes clinical case vignettes or research activities. The abstracts have all identifying features removed (i.e., names, institutional affiliations, etc.) before being sent to resident council judges. This year a total of 117 abstracts were submitted for the meeting. We are excited to be able to publish the three resident and the sole student winning presentations at this year’s competition selected by a panel of judges. All abstracts were presented at the Associates Meeting held virtually due to the COVID-19 pandemic on January 22, 2022. We would like to thank the Journal of the Louisiana State Medical Society and appreciate its efforts to publicize the hard work of these trainees Shane Sanne, DO, FACP Co-Chair, Louisiana Associates Liaison Committee Miranda Mitchell, MD Co-Chair, Louisiana Associates Liaison Committee Shahzeem Bhayani, MD Co-chair, Louisiana Student Liaison Committee Catherine Hebert, MD, FACP Co-Chair, Louisiana Student Liaison Committee Angela Johnson, MD, FACP Governor, Louisiana Chapter ACP
RESIDENT ABSTRACT WINNERS BILATERAL THALAMIC GLIOBLASTOMA MULTIFORME PRESENTING WITH APHASIA G Unis MD, E Philon DO Department of Medicine, Ochsner Medical Center, New Orleans, LA
INTRODUCTION: Bilateral thalamic lesions on brain Magnetic Resonance Imaging (MRI) represent a unique and unusual radiographic pattern. While unique, the differential for bilateral thalamic lesions is broad and can include cerebrovascular disease, toxin or metabolic syndromes, posterior reversible encephalopathy syndrome, viral infections, and neo- and paraneoplastic processes. CASE: A 55-year-old male with hypertension and type 2 diabetes presented with an acute aphasia of 5 hours in duration and general malaise prior to admission but denied other significant symptoms. Physical examination at the time of admission was negative for neurological abnormalities including cranial nerve testing, as well as being fully alert and oriented with appropriate mentation. He was afebrile, slightly hypertensive with a blood pressure of 149/96, and without oxygen requirements. Laboratory studies were within normal limits on admission however, computed tomography of the head demonstrated Department of Medicine, Tulane Health Sciences Center, New Orleans, LA INTRODUCTION: Hyperammonemia is often the result of liver pathology. When hyperammonemia is not the result of liver disease, an occult disorder of metabolism must be on the differential for unexplained hyperammonemia, such as a urea cycle disorder. CASE: A 57-year-old man with recovered systolic heart failure, atrial fibrillation, hypertension, and cervical neck fracture status post recent cervical spine corpectomy and fusion presented with worsening dysphagia and neck discomfort and was found to have a cervical fluid collection. He had no known underlying liver disease and denied significant alcohol history. He received a dexamethasone taper and a lumbar drain. He was later admitted to the intensive care unit (ICU) for unstable atrial fibrillation with
subtle diminished density within the left thalamus. MRI imaging of the brain demonstrated bilateral thalamic enlargement with diffuse T2/FLAIR signal hyperintensity. Lumbar puncture was obtained and routine cerebral spinal fluid (CSF) studies in addition to viral, bacterial cultures, and autoimmune studies were ordered. The patient was found to be positive for West Nile Virus (WNV) but with a negative WNV polymerase chain reaction (PCR) and toxoplasmosis IgG positive results. The patient was treated empirically for toxoplasmosis but failed to improve. Repeat MRI was obtained and demonstrated new enhancement which prompted a brain biopsy of the temporal lobe. Pathology showed WHO Grade IV glioblastoma multiforme and the patient was referred to oncology.
DISCUSSION: This rare and unusual disease, while previously described in the literature highlights the broad differential for bilateral thalamic lesions found on brain MRI and represents a unique learning case. SEVERE NONCIRRHOTIC HYPERAMMONEMIA: WHAT UREA-LLY SHOULD CONSIDER S Wu, C Basilio MD, MPH
rapid ventricular rates. In the ICU, the patient became more somnolent and was unable to follow commands. Encephalopathy workup revealed elevated BUN with normal creatinine, ammonia of 772, and mildly elevated transaminases. Liver workup was normal. Workup for inborn errors of metabolism showed mildly decreased citrulline. Urine and plasma amino acids were otherwise normal. His hyperammonemia resolved and his mentation improved with lactulose three times daily and rifaximin twice daily. Urea cycle disorder gene panel and further genetic workup is ongoing. Patient will follow up with genetics after discharge.
DISCUSSION: Patients with elevations of ammonia present with encephalopathy, which may progress quickly to cerebral
10 J LA MED SOC | VOL 174 | SUMMER 2022
herniation. Survival requires immediate reduction of ammonia levels. Although the differential for hyperammonemia is broad, inborn errors of metabolism (IEM), like a urea cycle disorder, should be considered when hyperammonemia is of unclear etiology. Although IEMs often have early age of onset, urea cycle disorders have multiple modes of inheritance and can present
at later stages. IEMs may also be unmasked by steroid therapy, which is plausible in this patient who was on a steroid taper prior to his hyperammonemic state. Treatment for a potential IEM begins prior to confirmation of an etiology. Geneticists should be consulted early on for evaluation and management.
MASQUERADING AS TTP: AN INSIDIOUS PRESENTATION OF B12 DEFICIENCY M Zoya MD, M N Salloum MD Department of Medicine, Louisiana State University, Shreveport, LA
INTRODUCTION: Pseudothrombotic microangiopathy is a rare presentation of B12 (cobalamin) deficiency. Patients appear ill with elevated reticulocyte count, lactate dehydrogenase (LDH), and total bilirubin with low haptoglobin, platelet count, and anemia - deceivingly suggestive of thrombotic thrombocytopenic purpura (TTP), a type of true and deadly microangiopathic hemolytic anemia. CASE: A 36-year-old female with hypothyroidism presented for anemia with a hemoglobin of 5.1 g/dL and symptoms of fatigue, shortness of breath, palpitations, sweats, chills, vomiting, 54 lb weight loss, easy bruising and tingling in her fingertips and toes for one month. Exam was unremarkable other than pallor. She was found to have an LDH >4,000, haptoglobin <4, platelets as low as 13,000 k/ul, and peripheral smears showing hyper segmented neutrophils and schistocytes. B12 level was normal (295 mg/mL) and methylmalonic acid (MMA) was 1.56 μmol/ mmol. Thyroid function panel was near normal. With fear of TTP, she received high dose IV steroids and three days of plasma exchange with minimal improvement in condition. ADAMTS13 is surprisingly found to be negative. Suspicious of B12 deficiency,
Hematology recommends daily B12 injections and her symptoms improve. Intrinsic factor (IF) antibody is found to be positive and pernicious anemia is uncovered. DISCUSSION: Malabsorption, not diet, is oftentimes the culprit of B12 deficiency. Most of the absorbed form is done by binding to IF produced by gastric parietal cells, which enhances absorption of B12 in the terminal ileum. Pernicious anemia causes malabsorption via antibodies that impede the B12-IF complex - either targeted at gastric parietal cells or IF itself. In severe cases, it can present with tissue hypoxia symptoms such as shortness of breath in the setting of elevated LDH, reticulocyte count, total bilirubin with low haptoglobin, hemoglobin and platelets. Unlike TTP, the reticulocyte production index (RPI) is <2.0% (reflects inadequate bone marrow response), will not improve with plasmapheresis, MMA will be elevated and median LDH is 3000 (median 1400 in TTP). B12 levels may appear falsely normal in pernicious anemia because of buildup of homocysteine and MMA as a consequence of high levels of IF-Ab, which alters the lab assay.
STUDENT ABSTRACT WINNER THE CURIOUS CASE OF NEUROMYELITIS OPTICA L Gawey BS, AQ Nguyen DO, PhD Department of Internal Medicine, Louisiana State University Health New Orleans, LA
INTRODUCTION: Neuromyelitis Optica (NMO) is an autoimmune inflammatory demyelinating disease that tends to affect the central nervous system. NMOSDs are very rare with prevalence ranging from 0.37 to 10 per 100,000 with median age of onset 32-41 years. CASE: A 24-year-old female with migraine headaches presented with a one-month history of rapidly progressive right- sided vision loss and right-sided headache associated with photophobia, pain, and flashes with eye closing. Vitals were unremarkable. Physical exam was significant for complete right eye blindness without visual field defect. Dilated ophthalmology exam showed Grade III optic disc edema with surrounding disc flame hemorrhages in the right eye. Laboratory studies were all within normal limits. Magnetic Resonance Imaging and Magnetic Resonance Angiography of the brain showed abnormal contrast enhancement and T2 hyperintensity involving all segments of the right optic nerve and proximal right optic tract, suggesting severe optic neuritis. Further serologic testing revealed a positive AQP-4 receptor antibody titer of 15.3 U/mL (negative < 2.9 U/mL), and final diagnosis of Neuromyelitis Optica. Computed Topography of the chest, to determine the primary etiology of NMO, revealed a pulmonary lesion. Pathology confirmed a mucinous lung
adenocarcinoma. She subsequently underwent right lower lobe lobectomy with mediastinal lymph node dissection that was negative for metastatic disease. She initially received four rounds of plasmapheresis and rituximab with stabilization of symptoms for NMO. Her symptoms improved after treatment for NMO and lobectomy. DISCUSSION: NMO is often associated with antibodies to aquaporin-4 (AQP-4) channels, which are the most abundant water channels in the central nervous system. Hallmark features of NMO spectrum disorder (NMOSDs) include acute attacks of bilateral or rapidly sequential optic neuritis or transverse myelitis in conjunction with seropositive for AQP-4 antibodies. Areas of CNS inflammation in NMO tend to correlate with the expression pattern of AQP-4 and corelate in frequency with relapsing disease, optic neuritis, or longitudinally extensive transverse myelitis. NMO spectrum disorders (NMOSDs) can often develop as paraneoplastic disease secondary to cancer particularly of breast and lung. AQP-4 positivity in NMOSD can serve should raise concern for potential malignancy screening in individuals positive for AQP-4. ■
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LOUISIANA MEDICAL POLITICAL ACTION COMMITTEE LAMPAC
MEMORANDUM
Regardless of our idealistic nature as physicians, the past several years have clearly indicated a need for all of us to get in the trenches to fight for our patients and the practice of medicine. Politics matters. LSMS has full time lobbyists working year-round to protect us and our patients. They can’t do it alone. As a physician, you need to engage in advocacy with your legislators. Today we are urging you to also consider joining us a LAMPAC member. As leaders of the political action committee, we are launching efforts to reenergize the political action committee which like so much of our lives has been impacted by our required focus on COVID. The last few years have properly focused on the pandemic and its surrounding issues limiting our time and ability to promote and support our PAC. However, the reality remains that some of the most important work we do on behalf of physicians involves politics. Many of the groups who regularly oppose us at the capitol are heavily invested in the political process, outspending us significantly to elect legislators who will support laws to benefit them. We need to be in a position to counter their efforts which requires us to band together as a profession and put our money into these efforts. Our goal is to engage 250 new donors before the end of 2022. In July, we will be heavily recruiting throughout the LSMS membership. If you can, please commit now and help us reach our goal by scanning the QR code and contributing early.
Should you have questions, please contact Maria Bowen (mbowen@lsms.org). This is important. Engage. Advocate. Commit. Join LAMPAC.
Susan Bankston, MD LAMPAC Vice Chair
John Noble, MD LAMPAC Chair
“ The Louisiana Medical Political Action Committee allows physicians to more easily engage in the electoral process. It is a separate organization from LSMS and contributions made to it are voluntary. Donations are quick, easy and powerful!
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LEGISLATIVE RECEPTION Physicians and guests with the Physician Coalition of Louisiana gathered the evening before White Coat Wednesday with members of the Louisiana Legislature.
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WHITE COAT WEDNESDAY White Coat Wednesday is an opportunity for our members to join colleagues for a day of advocacy at the Louisiana State Capitol. This is their chance to wear a white coat and be a part of the advocacy team. Members learn more about issues their profession faces at the legislature, gain a better appreciation of what goes on at the Capitol, meet their legislators, and advocate for their profession.
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2022 REGULAR LEGISLATIVE SESSION IS A WRAP
• SB 175 by Sen. Regina Barrow would have allowed independent practice of nurse practitioners after fewer than 6 months under a collaborative practice agreement. • HB 543 by Rep. Joe Stagni would have allowed independent practice of nurse practitioners after less than a year under a collaborative practice agreement. It created a new category of collaborators called a “consulting practitioner” which would have included other nurse practitioners. The bill further included language granting “global signature authority” to nurses.
On June 6 at 6 PM, the Louisiana Legislature constitutionally adjourned Sine Die, ending the 2022 Regular Legislative Session!
In a session that saw 6 significant scope bills, 38 anti-vaccine bills, 4 noncompete bills, 2 medical malpractice bills, 1 anti-trust bill, an embedded veto session and so much more, organized medicine is breathing a sigh of relief that we were able to fend off so many bills that would have negatively impacted you. However, we are happy to share that we did successfully pass several bills aimed at easing some of your administrative burdens related to insurance. A huge thank you to the many physicians who joined us at the Capitol to testify for and against legislation. While there, they often served as volunteers for the First Aid Station, too! We hope to have many of you join us again and encourage those of you with an interest to reach out for opportunities that help you stay involved. We’ll start with the embedded veto session – not because we were involved in that session but because that is the day the Physician’s Coalition hosted White Coat Wednesday. The 109 physicians and guests who attended this year’s advocacy day got to witness history in watching as both bodies overturned Gov. John Bel Edwards’ veto of congressional redistricting maps. Our thanks to the many lobbyists and staff members who helped pivot on short notice to accommodate the necessary changes required by the veto session’s schedule. The event proved very successful in giving member physicians the ability to discuss medical issues with legislators. While we don’t currently have a date for 2023, we are already working on plans for next year’s event and encourage you to watch for updates in early January once the Speaker’s office releases the event calendar.
Neither bill was moved.
The physician assistants brought one bill, SB 158 , authored by Sen. Jay Luneau which sought to:
• Eliminate direction, control and supervision by a physician
• Replace clinical practice guidelines with a collaborative practice agreement establishing a scope rather than allowing for physician delegation
• Eliminate physician informed concurrence of the physician assistant’s actions
• Remove all required physician engagement during a declared state of emergency
• Allow physician assistants to be employed by an “other health care organization or entity.”
SB 158 did receive a hearing in Senate Health and Welfare and was reported favorably. It was returned to the calendar on the Senate floor. However, the author was very adamant that he would be back next year if we don’t all work together to find a solution to the scope battles. The biggest scope challenges this year actually came from the pharmacists who proposed 3 aggressive bills aimed at moving pharmacists directly into the field of medicine. The first of the 3 bills was authored by Senate Health and Welfare Committee
SESSION. SCOPE. REPEAT.
This year’s six scope bills were offered allowing for the practice of medicine by advanced practice registered nurses, physician assistants and pharmacists.
The nurses offered two pieces of legislation this year:
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DESPITE HEAVY LOBBYING FROM THE CHAIN PHARMACIES, WE WERE SUCCESSFUL IN KEEPING THE BILL FROM BEING RECONSIDERED
Chair Fred Mills. SB 329 would have:
• Allowed a pharmacist to render any patient care services approved by a protocol development committee housed under the Louisiana Board of Pharmacy
violation of the statute
• Allowed a pharmacist to order, administer and interpret laboratory tests
• Provides an exemption for healthcare providers under federal mandates to ensure all employees are vaccinated as a condition of Medicare or Medicaid participation. Following its passage, many physician groups did request a veto from Gov. John Bel Edwards. The veto was granted. If the legislature chooses to convene a veto override session, HB 54 can be brought up for a vote. If the bill is not brought up or fails to receive the requisite number of votes to override the Governor, it will not become law.
• Allowed a pharmacist to prescribe and dispense non- controlled prescription medications, prescription devices and durable medical equipment.
SB 329 was reported out of committee before being returned to the calendar on the Senate floor where it died upon adjournment.
Sen. Regina Barrow offered SB 296 which allowed for pharmacist clinical services within Medicaid. Because of a very large fiscal note, the bill was dually referred to both Senate Health and Welfare and Senate Finance. Ultimately the bill died without receiving a hearing in Senate Finance. On the House side, Rep. Chris Turner brought HB 424 which would have allowed pharmacists, pharmacy interns and certified pharmacy technicians to give any immunization to any child over the age of seven. This bill was reported favorably from House Health and Welfare. It was brought up on the House floor for a vote where it failed to pass by 1 vote. Despite heavy lobbying from the chain pharmacies, we were successful in keeping the bill from being reconsidered. It remained on the House calendar and died at adjournment.
NONCOMPETES ARE A NON-STARTER.
Four noncompete bills were filed in 2022 to include a LSMS requested one. Sen. Jay Morris filed SB 385 specific to physician contracts at our request. Unfortunately, legislative leadership did not have an interest in seeing any noncompetition legislation move and successfully kept them all bottled up in committee where they died upon adjournment:
• SB 385 by Sen. Jay Morris was requested by LSMS and was specific to physicians.
• SB 238 by Sen. Cleo Fields was very broad and addressed the full spectrum of employee contracts.
VACCINE-PALOOZA.
• SB 427 by Sen. Franklin Foil was specific to physicians employed by state entities.
Nearly 40 anti-vaccination bills were filed in Louisiana this year. Due to the sheer volume of bills, we’ve provided a separate list, on pages 22 and 23. However, it is noteworthy to mention that for the first time, the words vaccine and criminal justice committee were used together. HB 54 by Rep. Larry Bagley would have criminalized anyone who asked vaccination status of persons seeking entry to any premises. This would have included everywhere from hospitals and physician offices to public properties to home-based businesses. The original penalties included both jail time and monetary fines. The legislation was amended throughout the process eventually being finally passed in a posture which:
• HB 1037 by Rep. Mandie Landry also addressed all noncompete clauses and very closely mirrored the White House’s Executive Order on noncompetes.
MEDMAL MATTERS.
The arguments related to standard of care under emergency situations are many and complex. SB 220 by Sen. Katrina Jackson and SB 346 by Sen. Jimmy Harris both focused on how to make the standard of care relate to the actual emergency. After many meetings between the interested parties and two hearings before the Senate Judiciary A Committee, the authors pulled back their bills and agreed to continue working towards language for legislation next year. Thank you to Dr. Jeff White from Shreveport for testifying before the committee and working with the stakeholders to offer alternative language.
• Is limited to governmental entities and public educational institutions
• Prohibits discharging an employee from employment within the above solely for refusing a COVID vaccine
• Creates a liability for damages if an employee is discharged in
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THE CONSTITUTION DOES NOT CONFER A RIGHT TO ABORTION; ROE AND CASEY ARE OVERRULED; AND THE AUTHORITY TO REGULATE ABORTION IS RETURNED TO THE PEOPLE AND THEIR ELECTED REPRESENTATIVES.
ANTI-TRUST PROTECTIONS GET CONTROVERSIAL.
Rep. Barry Ivey’s amendment requires the Louisiana Department of Health to promulgate rules establishing an exclusive list of anomalies, diseases, disorders and other conditions to be deemed medically futile. [NOTE: As this edition of the Journal is going to press, LSMS is reviewing the Supreme Court’s decision. We will be working with other groups to provide a more comprehensive report specific to this issue in a supplement.]
SB 276 by Senate Insurance Committee Chairman Kirk Talbot started as a “placeholder” bill but was amended during its committee hearing to become one of the most controversial bills of the session. As amended, it exempted all managed care organizations from any provision of the law including Louisiana anti-trust statutes. It also included retroactive language which would have removed Louisiana’s largest health insurer from a lawsuit currently moving through the courts. The bill failed to pass by a vote of 14 to 20. The author gave notice of reconsideration which allowed it to be considered for a second vote at a later date. Despite intense lobbying efforts to pass the bill and amendments to address concerns of legislators, the insurance companies fell one vote short.
RELIEVING BURDENS.
On the positive side of the equation, LSMS and other groups did successfully work together on and pass a package of bills aimed at easing administrative burdens. Additional details on the bills provided on pages 20 and 21. Act 432 (SB 112) by Sen. Robert Mills mirrored the Texas “gold card” bill and would have provided relief from prior authorizations in certain circumstances. Despite compelling testimony from physicians and amendments requested by the insurance companies, the Senate Insurance Committee was not inclined to report the bill as written. When reported, the bill had been amended to require each insurance company to develop and post its own version of prior authorization relief for providers. While this is a unique step forward, we remain committed to bringing legislation in the future if this does not provide you with results. Act 166 (HB 339) by Rep. JP Coussan focuses on coordination of benefits and prohibits health plans from pending, delaying, or denying payment to a provider on the basis of the insured’s failure to provide notice of another insurance policy. SB 59 by Sen. Fred Mills and Rep. Larry Bagley prohibits a Medicaid MCO from requiring any enrolled providers to participate in a prepayment review unless the review is implemented directly by the Louisiana Department of Health and is in accordance with the provisions of the Medical Assistance Programs Integrity Law. Act 143 (HB 286) by Rep. Chris Turner stipulates that any healthcare provider who maintains hospital privileges or is a member of a hospital medical staff with a licensed hospital shall be considered to have satisfied and shall otherwise be exempt from having to satisfy any credentialing requirements of a Medicaid managed care organization. ■
ABORTION AND LOUISIANA TRIGGER LAWS.
On June 24, 2022, the US Supreme Court released its opinion in Dobbs v. Jackson. The ruling overturned Roe v. Wade and held, “The Constitution does not confer a right to abortion; Roe and Casey are overruled; and the authority to regulate abortion is returned to the people and their elected representatives.” Until this ruling, Roe v. Wade which was decided in 1973 governed policies related to abortion. Thus, any discussions regarding restrictions on elective abortions in Louisiana (and elsewhere) had been largely hypothetical. Now, the conversation is very real. Louisiana has had “trigger laws” on the books for years (laws that would only go into effect if Roe were overturned or a change occurred at the federal level allowing the states authority to further restrict abortion). Sen. Katrina Jackson passed SB 342 during the session which creates mandatory imprisonment and fines for physicians who perform elective pregnancy terminations in most circumstances. Physician advocates worked throughout the legislative process to tighten language that was considered unclear and to add an exception for a medically futile pregnancy. While the author did not support this effort, she did not fight the will of the legislature in providing both clarity and the additional exception. Other exceptions include life or serious bodily injury to the mother and both the removal of and use of methotrexate for ectopic pregnancies. A number of amendments were proposed and failed, including an exception for rape and incest. Unfortunately, on the House floor during debate, language was adopted that added another layer of complexity.
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